To the Editor: In his State of the Nation address on 3 June 2009,1 President Jacob Zuma lauded the 'functional constitutional democratic system' of South Africa, as demonstrated by the 'seamless transition' in the political leadership. This is an admirable achievement, and many countries, including my native Germany, struggled seriously to reach such political stability.

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However, political stability and functional democracy are no guarantee of an equitable and sustainable health care system. The USA has an estimated 45 million people, approximately equal to the total population of South Africa, not covered by health insurance and therefore without access to primary health care (source e.g. Kennedy2). The World Health Assembly recently re-emphasised its commitment to 'Primary Health Care and Health System Strengthening' as in the Declaration of Alma-Ata (1978) and the United Nations Millennium Declaration (2000).3 Faced with a health care system that produces mediocre outcomes in terms of population health parameters, despite having one of the world's highest per capita expenditures on health care, Michael Porter advocates a value-based system.4 Porter speaks of 'increasing value for patients  the health outcomes achieved per dollar spent', and the focus is therefore not on 'substitute values' such as 'free markets' and 'socialisation of key industries'. I am still traumatised by the proceedings of last year's South African Medical Association conference on 'The future of health care in South Africa  how will it be provided and funded?'.5 SAMA is regrouping behind a new Secretary-General, and the challenges that our country, and especially the health sector, face are recognised and documented (e.g. National Department of Health6). Yet the Boksburg conference gave me the impression that there is no coherent strategy in our Medical Association, and no viable concept for a sustainable South African health care system. Instead, there is factionalism that might be described as two 'camps': the 'private sector camp' with a 'change-whatever-you-want-in-the-public-sector, but-don't-touch-our-system' approach, and the 'activist camp' with a 'change-it-all, change-it-now' approach. Neither approach is appealing, nor do they seem sustainable. If we allow further 'Americanisation' of our health care system, with rising expenses fuelled by inefficient interventions and an internal 'brain-drain' of health care professionals from the public sector, the eventual collapse of the public sector will not leave a blessed private island unharmed. On the other hand, the public health sector is seriously challenged by infrastructural, organisational and staffing shortfalls. Whether one blames this on the legacy of previous socio-political systems or on current corrupt and nepotistic practices depends on one's political affiliation. Regardless of these discussions, it is obvious that the struggling public health sector cannot easily be fixed by pouring a large amount of money into it.

I plead for an intensified, open-minded and outcome (value)-orientated discussion about the future of the health care system in South Africa. The current situation is unsustainable and change is inevitable. As a medical profession, we might adopt an ostrich approach and wait for this change to happen to us, or actively tackle the challenge and play a leading role in the 'revitalisation' of health care in our country. To avoid uninformed political 'quick-fix' solutions, I would prefer the latter and for SAMA to be the vehicle for our profession to shape these changes.